A discussion of all topics in Health care IT with an emphasis in Health Information Exchange, EHR and Telemedicine.

Wednesday, May 14, 2008

Telemedicine Demonstrating Value

Here is an interview (see below) of Dr McConnochie on a Rochester based Pediatric Telemedicine program "Healthy Access". There have placed telemedicine equipment at childcare programs so a child can have a tele-consult with a physician without leaving the child care center in case of illness. This has proved to be a real convenience for families, but has also shown to reduce ED visits. See this press release:Telemedicine a Cost-Effective Alternative to ER VisitsThe bottom line from their study: A 24% reduction in ED visits in the group of children using telemedicine and a savings of $14/child per year for the insurers. Also see David William's Healthcare Business Blog for his thoughts on this program.

Rand: For many busy adults, balancing busy careers and parenting is tough. When a child gets sick at day care or school, figuring out how to get them to the doctor’s office can be a challenge. But a project designed at the University of Rochester Medical Center used technology to bring the doctor’s office to child care centers and schools. The project is called Healthy Access and began in 2001 in five inner-city child care programs in Rochester, New York. Today the telemedicine network has grown to 22 sites, including suburban elementary schools and child care programs and 10 primary care practices. We’re joined`now by Dr. Kenneth McConnonchie, the principal investigator for the project. Dr. McConnonchie welcome, would you please tell us how Healthy Access works?

Dr. McConnonchie: Well, let’s say we have two-year old Sally, and she wakes from nap time with a fever or holding her ear. As with any child care program, the parent is contacted, but instead of the dreaded call to come pick up your child and don’t come back without a doctor’s note, child care staff, in this case, offers telemedicine as an option. Almost always, the parent chooses telemedicine. The trained child care staff person, known as the telehealth assistant, also uses this contact to obtain any history about the illness episode not already known. Then, at the child care site, the telehealth assistant collects additional information, including images, video clips and audio files, about the child’s condition and medical history. We use a digital camera with special attachments to take detailed, high resolution eye, ear drum, mouth, and skin images. We also capture lung sounds using an electronic stethoscope.

Rand: Is all this technology a bit scary for small children?

Dr. McConnonchie: Some may wonder whether the child might be frightened by the whole process, given the fact that usually a parent is not present at the telemedicine visit. Experience, however, shows that quite the opposite is true. Consider the fact that child care and school are like a home- away-from-home for children that they serve. Staff there care for these children almost every day. In child care, many children spend more waking hours with their teacher than with their parents. In contrast, young children know the doctor’s office only as a place they go for shots, and that’s a scary place. Another advantage of the child setting, child care setting at school, is the children love to see themselves on TV, so to speak, and that’s their experience with telemedicine.

Rand: So then what happens with all the information that’s collected?

Dr. McConnonchie: Having acquired all the information, the information is then sent by the telehealth assistant to the child’s primary care practice, where a clinician can use the information to diagnose or treat the patient. If necessary, the clinician conducts a live video conference with the patient, staff, and sometimes parents, to help diagnose the child. If a prescription is appropriate, after diagnosis, the physician can instantly fax it to the pharmacy for delivery to the child care center or school. Once the visit is complete, parents get a personalized letter about the visit and any useful information that the doctor wants them to have, such as a standard handout on ear infections. With an evolving illness, the clinician generally discusses findings and recommendations directly with the parents by phone. For children with a primary care doctor who is not participating, or who have no PCP [primary care physician], the visit is done by the default clinician. This responsibility is usually filled by our primary care pediatric practice at the University of Rochester Medical Center. All local insurance organizations, including Medicaid, Managed Care and SCHIP plans are reimbursing for telemed visits. The default clinician would also see children with no insurance in case there was a participating PCP who’s group refused, so that’s an overview of how it works.

Rand: Dr. McConnochiehow effective has your network been?

Dr. McConnonchie: Well, to date, we’ve conducted more than 5,500 visits between child sites and the ten physician offices using telemedicine. Since the program began, we’ve been able to show a 63% reduction in absences from child care due to illness. As we like to put it, it’s health care when and where you need it by people you know and trust.

Rand: What’s been the reaction of parents react to this technology?

Dr. McConnonchie: Well, some parents were initially skeptical, understandably so and appropriately so, about using telehealth to treat their children, but as the program moved along, parents have gained confidence in telemedicine. Parents tell us that without telemedicine in place, illness in their children result in much more – would result in much more time lost from work, more in-person doctor visits, and more emergency department visits, and our data supports their claims.

Rand: So, what’s the next step for this program? Where do you see it going?

Dr. McConnonchie: We think the technology could be used in many additional settings. Obvious examples are group homes for developmentally disabled, assisted living facilities, summer camps. The burden of morbidity for children or adults in each of these settings is high, yet access to care in these settings is often problematic. For example, in-person access for a developmentally delayed child or an elderly individual in an assisted living center often requires a wheel chair van and multiple attendants. Retail-based medical clinics are rapidly developing in many communities around the United States. While extremely appealing to the consumer because of their convenience, retail- based clinics disrupt continuity of care with the medical home. People are seen in retail-based clinics by a nurse practitioner in the store, not by their doctor’s office. Retail-based telemedicine access points, in contrast, would provide the same level of convenience as retail-based clinics while maintaining continuity of care. People would go to the store for access, but with telemedicine, they could be readily seen by a clinician from their own doctor’s practice.

Rand: Regarding the training involved in this program, what does it take to become a telehealth assistant?

Dr. McConnonchie: Well, that’s a very important question and for long-term sustainability, that’s an important issue. The telehealth assistants, as we call them – actually we call them CTAs for Certified Telehealth Assistant. We train them and we certify them. The certification reflects the fact that they’ve gone through the training program and then demonstrated, over a couple of months, visit by visit evaluation, including sample visits or trial visits – that they can perform at a high level. So then we issue – having gone through this – then we issue the certification, and if someone doesn’t do enough visits to maintain their certification, they’re de-certified. But the basic training, the initial training, just takes a couple of weeks and I think one of the strengths of this whole system is that we, you know, we can take a child care staff person without – who never had – most of whom have not had prior health care training. Some have been trained by – been trained as nursing assistants, CNAs, Certified Nursing Assistants, who work in assisted-living facilities, for example – and with relatively brief training, get them up to speed.

Rand: Who funds the staff and training?

Dr. McConnonchie: Well, at the child care site, or the child-end or patient-end of the process, the telehealth assistant is, in most settings, is someone who’s employed/hired by the child site itself. Now, in many day care centers, particularly large ones, there is a health person. This expands the health person’s role and gives them a lot more tools. I would say it makes them a lot more useful, so given that child sites have – child care sites have found that they’re now attracting families that they haven’t attracted before, simply because they’ve got child care. They have found that it’s worth their while from a program development perspective. For sites and many child – certainly many of the city child care sites are also a part of family advocacy programs. Those sites take the perspective of, you know, they want to do everything they can to support families, get families back on their feet, to keep parents on the job, and the like. So they go out and raise their own funding to support this health person or the telehealth assistant. City schools are a little different. Their mission is different. Their budgets are much bigger and they’re much less, you know, personally oriented. Charter schools and actually the parochial schools, in our experience, have functioned more like the, like the child care centers that are very family oriented. So, the – at this point, that’s where the funding comes from. Our very first programs, we provided the funding for the telehealth assistant, so it came from our federal funding. Actually, back then, it was the U.S. Department of Commerce Technology Opportunities Program, the very first programs.

Rand: Dr. McConnochie, let’s talk technology for a minute. If someone is thinking about starting this up, what equipment do they need?

Dr. McConnonchie: Well, we have – we started off with commercially available pieces and we put them together into a functioning model, but certainly not a very efficient model, and certainly not one that was reliable enough or user-friendly enough that a busy pediatrician in their office practice would tolerate it. Faced with, you know, the implied problems, a commercial venture has grown out of our efforts. It’s called TeleAtrics. The initial role, from my perspective, as the Director of Healthy Access – the initial job of TeleAtrics was to develop, you know, the kind of platform that was needed, that – and basically the platform is a web based platform. There’s a central server where records of all the visits reside. At the – you know, at the child site, it’s a very secure system. It’s a lock-down system accessible only through a bio-metric log on by the telehealth assistant. The bio-metric log on is a fingerprint reader. People can’t be surfing the web at that end. And it’s basically a computer dedicated – it’s basically a plain vanilla PC with a couple of peripheral devices, the main – there’s a Logitech video conferencing camera, pretty simple straight forward. Anybody can set that up. There’s – what’s called a Camscope and that’s kind of the all-purpose camera which has different attachments that, kind of, optimize it for looking at ear drums and looking at throats or skin or eyes that actually – the Camscope can also be used to focus across the room. It can be used as a video conferencing camera. It’s a very, very flexible and useful tool. In addition, there’s the electronic stethoscope and that’s basically it. As I said, it all attaches to a plain vanilla PC which is locked down. The software that resides on the server guides the telehealth assistant through the process. We have a training manual that guides them through the process and makes it very clear under what circumstances you definitely need to get ear images and under what circumstances you definitely need to get lung sounds. You don’t need to get lung sounds on every child, certainly not a child whose chief complaint is a skin rash, particularly if the child is acting well. But, so the software guides and teaches, if you will, for the telehealth assistant.

Rand: What about on the clinician’s end?

Dr. McConnonchie: The software at the other end, at the clinician end, first of all, it captures and displays, in an efficient way, the information that – both the text information, as well as the images, and video clips and lung sounds that are – have been captured by the telehealth assistant, what the – actually at the clinician end – what the clinician sees. On the left hand side of his monitor is a waiting room, where children waiting to be seen by telemedicine are listed, and then there’s a media column – if he clicks on one of those visits, a media column and the rest of the visit opens up. The media column is right there and he, basically, has thumbnails of all the images and audio clips and video clips, and then right next to that is the text that’s summarized from the telehealth assistant, and then you scroll down, open and expand boxes for recording through the standard physician’s history, past medical history is available.

Rand: This is Health Care 411, if you just joined us we’re talking with Dr. Kenneth McConnochie, the principal investigator of the Healthy Access telemedicine project at the University of Rochester Medical Center. Dr. McConnochie how are you evaluating the impact of this technology on health care quality?

Dr. McConnonchie: A couple other simple, but, I think, very important measures are continuity of care with visits and also ability to complete visits. In terms of continuity of care, for children who have a participating PCP, the question is, what proportion of those visits do the – does the PCP squeeze in to his busy office practice? And basically, we’re asking them to squeeze those visits in as they come up. The answer is that it varies - some – but the average is about 83%. It varies from about 60% to about 95%. I think the 83% average is pretty darn good considering, especially, that so many of these visits would have ended up in the emergency department. Our – sort of prior to getting this going – we conducted some interviews at some inner city and suburban child care sites, and talking to the inner city families, we asked them – if you were to call your child’s practice in the afternoon about – your child’s sick and you really would like him seen today – 75% of parents said that they would be told to go to the emergency department. So, the point here is, obviously, the additional cost of the emergency department visit, but also, that’s not continuity of care, obviously. So there’s one important effect. The other effect, in terms of completing visits – by that, I mean, a visit seen by telemedicine – what, in what proportion of the time did the clinician feel comfortable/confident with both their diagnosis decisions and their treatment, and being able to, not just make treatment decisions, but actually implement the treatment, and that’s about 96% of the time. So, 96% of visits are completed. Obviously, this is not – you know, these are visits that arise in child care and school settings, that the child wasn’t sick, most of the time, when they went off to child care in the morning. So these are not terribly serious problems, but from a medical perspective, but they are quite serious from a social perspective if moms can get called and told to pick up the child.

Rand: Have you gotten any feedback from people who are in the actual doctor’s office, whose visits were interrupted by one of these calls?

Dr. McConnonchie: Well, yeah, not directly, cause they’re – and I wouldn’t expect to, cause no single visit is going to be interrupted. A doctor’s not going to get up in the middle of the visit and say, “Sorry, I’ve got to go take a telemedicine call.” The visits are completed. Now I am active as a clinician myself and our fairly busy primary care practice – what often happens is – the tele – not every telemedicine visit needs a – the real time video conference component. Many do not. So, I can do many other things that I’m doing – while I’m supervising residents, say, and then pick up the phone or look at the telemedicine visit and make my decision very quickly, and pick up the phone, call the parent or call the telehealth assistant, and just squeeze that in. So, basically, often the decision making part, it’s all so well presented and the images are so crystal clear, when things go well, as they usually do, my decision making just takes a matter of seconds. The communicating and the documentation takes a little more time, but it’s not something that I can’t do, you know, fitting it in between patients or between other things I’m doing in a clinical setting. So these visits are very efficient.

Rand: Have any of the parents expressed concern about sick kids being allowed to stay in the classroom?

Dr. McConnonchie: I don’t think so. It’s a question that comes up. You know, first of all, the issue of – does the child stay or go home – in the – that basically boils down to a decision between the parent and the child. I’m sorry – between the parent and the child care site. If the child care site says that your child cannot participate, is feeling so droopy that, you know, we have to spend – our staff has to spend so much time with your child that, you know, we can’t attend to other children, we can’t care for other children, we can’t teach other children – then, you know, the child needs to be picked up. It’s not an arguable point. The question of communicability – you know, there are, from a strictly medical perspective, you know, most of the times, the viruses that you’re dealing with are just ubiquitous. Children with a common cold, who could be coughing and sneezing and spewing those viruses all over the place – you know, the guidelines say that that child can stay. Um, the child with conjunctivitis, which is pink eye, which is a little more visible, from a specifically contagious disease perspective – that child is no more and probably less contagious than that child with a cold. You know, again, to me, that’s – from a medical perspective, I can put my two cents in and say what I just said, but the final decision is up to the child care site and the parent. – If the child care site – if their guidelines say the child needs to go home, the child needs to go home. That’s it.The American Academy of Pediatrics and their, sort of, school health handbook very much emphasizes the fact that most children with minor illnesses are safe for them to stay and that the decision to leave should be based, primarily, and in most instances, on the ability of the child to learn and participate.

Rand: It seems there are obvious advantages to parents and children – in terms of this being less disruptive to both of their everyday routines. Have you noted any other benefits?

Dr. McConnonchie: We have evaluated – we have published some preliminary analysis which has convinced the local – I should say preliminary analysis of cost effectiveness, which has convinced the local Medicaid, Managed Care, and commercial insurers in the Rochester area to continue reimbursement beyond the end of the current demonstration project for children who are at currently participating sites. We’re right now in the middle of a much more elaborate cost effectiveness analysis, including a few thousand children followed over various periods of time. We expect that this is going to show consistent with the preliminary analysis – that the Healthy Access telemedicine model is highly cost effective. Why? Well, many emergency department visits by children could have been handled via telemedicine. In our community, many problems that would have led to ED visits have now been managed by the telemedicine model instead. Our studies indicate that payers reimburse ED visits at least five to- seven-fold greater than for office visits or telemedicine visits for the same problems. So we anticipate substantial reduction in net health care costs for managing childhood illness, even after paying for telemedicine infrastructure, such as the telehealth assistants and the equipment. Considering the impact of telemedicine on absence from child care or school, and on parent absence from work, we expect that from a societal perspective – in other words, going beyond just the health care perspective – that cost effectiveness will be even greater. So, we’re optimistic based on our final analysis that insurers will expand telemedicine reimbursement for all children locally and, eventually, nationally.

Rand: Dr. McConnochiethank you so much for joining us today.

Dr. McConnochie: Well, thank you very much, it’s been a pleasure.

Rand: Dr. Kenneth McConnochie is the principal investigator of the Healthy Access telemedicine project at the University of Rochester Medical Center.

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